A nurse auscultates an adult client at the cardiac apex. Listen to the recording. Which finding should the nurse document?

The recording demonstrates a rapid irregularly irregular rhythm consistent with the acoustic pattern of atrial fibrillation. The nurse should document the observed rate and rhythm and correlate the finding with pulse, symptoms, and electrocardiography rather than diagnose from sound alone.

Use the scenario findings and timing to identify the safest response.

Connect the relevant cues to the nursing interpretation and action supported by the evidence.

Other responses are unsupported, mistimed, lower priority, or incomplete for this scenario.

Address immediate threats first and reassess after intervention.

For atrial fibrillation auscultation, document observed findings and avoid unsupported diagnostic inference.

James Heilman, MD - CC-BY-SA-3.0

• Irregularly irregular rhythm — A rhythm with no repeating pattern between beats.
• Apical pulse — The heart rate and rhythm assessed at the cardiac apex.
• Electrocardiography — Electrical rhythm testing used to confirm the cardiac rhythm.